Introduction to the Special Issue: Catalyzing State Public Health Agency Actions to Prevent Injuries and Violence

In 2014, the then director of the Centers for Disease Control and Prevention (CDC), Dr Thomas Frieden, published an article in the American Journal of Public Health that detailed 6 components necessary for effective public health program implementation.¹ Successful implementation of proven interventions requires overcoming barriers, including, as Frieden notes, “limited and unstable funding, lack of automatic means to track and improve performance, workforce limitations, and insufficient political commitment.”^1(p17) The article suggests that successful, sustainable implementation is linked to 6 key components: (1) innovations in science, medicine, evaluation, or systems; (2) a rigorously established technical package of evidence-based interventions; (3) management, including rigorous monitoring and evaluation, of interventions and effective human resource management; (4) partnerships, particularly between different levels of government agencies (local, state, federal) and between government agencies and nongovernmental organizations; (5) communication, using timely, effective, and sustained messages, particularly through new technology, to facilitate conversations and disseminate messages; and (6) political commitment, which is both bolstered by and bolsters the prior 5 components.¹

This special issue of the Journal of Public Health Management & Practice includes implementation science and practice examples that build on this foundation and illustrate a systems approach to application of these components within programs of CDC’s National Center for Injury Prevention and Control (CDC’s Injury Center) (Table). Many, if not all of the articles, address more than 1 component; indeed, this is the intent: effective programs include all 6 components.¹ All of the programs featured in the special issue required implementation of evidence-based strategies (component 2). However, none of the articles discuss this component in detail, primarily because extensive literature already exists for evidence-based programs, and the Injury Center has already developed several technical packages (https://www.cdc.gov/violenceprevention/pub/technical-packages.html) that specifically and thoroughly address this component. Thus, this special issue is devoted to the other 5 components: the systems that are critical to the successful implementation and coordination of the technical packages, for without these systems, technical packages are less likely to yield a population-level impact.

TABLE.

Crosswalk of Frieden’s 6 Components With the Special Issue Articles^a

Components Necessary for Effective Public Health Program Implementation	Article That Addresses Component
(1) Innovation to develop the evidence base for action	Smith et al, “Minding the Gap: New Approaches to Addressing the Research to Practice Chasm”
	Wilkins et al, “Connecting the Dots: State Health Department Approaches to Addressing Shared Risk and Protective Factors Across Multiple Forms of Violence”
	Armstead et al, “Indicators for Evaluating Community- and Societal-Level Risk and Protective Factors for Violence Prevention: Findings From a Review of the Literature”
(3) Effective performance management, especially through rigorous, real-time monitoring, evaluation, and program improvement	Nesbit et al, “Innovative Methods for Designing Actionable Program Evaluations”
	Armstead et al, “The Use of the Data-to-Action Framework in the Evaluation of CDC’s DELTA FOCUS Program”
(4) Partnerships and coalitions with public and private sector organizations	Smith et al, “The Power of Academic-Practitioner Collaboration to Enhance Science and Practice Integration: Injury and Violence Prevention Case Studies”
	Wilson et al, “Development of a Comprehensive and Interactive Tool for States to Use When Developing Violence and Injury Prevention Plans”
(5) Communication of accurate and timely information to the health care community, decision makers, and the public to effect behavior change and engage civil society	Wilson et al, “Development of a Comprehensive and Interactive Tool for States to Use When Developing Violence and Injury Prevention Plans”
(6) Political commitment to obtain resources and support for effective action	Deokar et al, “State Injury Programs’ Response to the Opioid Epidemic: The Role of CDC’s Core Violence and Injury Prevention Program”

^aAdapted with permission from Frieden.¹

The first component in the Frieden model is innovation. Innovation is the fostering of new science, technology, or methods either in framing issues or in conducting operations. Several of the articles in this special issue advance innovation by reframing how researchers and practitioners have traditionally approached their work, moving away from traditional functional (research or practice) or topical (youth violence, sexual violence) or both silos. For example, in their commentary, “Minding the Gap: New Approaches to Addressing the Research to Practice Chasm,” Drs Smith and Wilkins call for a systems approach in how the work is accomplished—a functional shift. They encourage the advancement of “Action Research” by scholar-practitioners who value and use theory and practice to inform their work, and who move seamlessly between the 2 domains, rather than specializing in one or the other. Wilkins et al approach innovation from a structural perspective in “Connecting the Dots: State Health Department Approaches to Addressing Shared Risk and Protective Factors Across Multiple Forms of Violence.” The authors discuss 2 state examples of maximizing state resources by focusing on the risk and protective factors that are common across multiple forms of violence. The shared risk and protective factors approach represents an innovation in how violence prevention and intervention strategies are designed, implemented, and evaluated.

Public health programs are designed to have a population-level impact. However, identification of proximal, population-level indicators to evaluate impact is challenging. In “Indicators for Evaluating Community- and Societal-Level Risk and Protective Factors for Violence Prevention: Findings From a Review of the Literature,” Armstead et al present the results of a comprehensive literature review of community and societal indicators to measure risk and protective factors for violence. The review presents innovative indicators that can be accessed through publically available data sources and measure community-level phenomena truly at the community (vs individual) level. These indicators represent opportunities to map the trajectory of community and societal changes.

Innovations not only are limited to innovations in science but can also reflect innovations in approaches. Nesbit et al and Armstead et al describe innovative, effective performance management systems (component 3) that resulted in actionable evaluation data from the Core Violence and Injury Prevention Program (Core VIPP) and Domestic Violence Prevention Enhancements and Leadership Through Alliances, Focusing on Outcomes for Communities United with States (DELTA FOCUS). Both articles describe structured performance management systems that incorporated the ability to shift the evaluation structure in response to feedback and data from the grantees. Both Nesbit et al and Armstead et al also describe an iterative process of working collaboratively with partners to ensure that the program evaluation facilitated state and local continuous quality improvement and tracked intended impacts.

Partnership (component 4) is a key theme present in many of the special issue articles; however, it is the central theme in the Smith et al article, “The Power of Academic-Practitioner Collaboration to Enhance Science and Practice Integration: Injury and Violence Prevention Case Studies.” This article presents case examples of academic professionals engaging with community partners and health departments to design, implement, and evaluate strategies to prevent violence and injury. These examples highlight the value of partnerships more broadly and the benefits of the scholar-practitioner and action research approach detailed in “Minding the Gap: New Approaches to Addressing the Research to Practice Chasm.”

Partnership and communication are interdependent; partnerships thrive when communication is clear and open, and clear and open communication fosters more effective partnerships. In, “Development of a Comprehensive and Interactive Tool for States to Use When Developing Violence and Injury Prevention Plans,” Wilson et al describe a process of working with partners to create a state strategic plan for injury and violence prevention that communicates the mission, goal, and key activities to ensure all understand their organizational or individual role and how their piece connects to the broader mission.

All 6 components, including partnerships, are heavily influenced by component 6 (political commitment). Political commitment often influences which groups one chooses to partner with; the content and method of communicating messages; how programs are managed; and how, or even if, innovations occur. Deokar et al describe the central role political commitment played in early state response to the opioid overdose epidemic; for example, North Carolina’s Secretary of Health and Human Services appointed a taskforce to examine the issue and in 2004 issued recommendations to prevent deaths from unintentional drug overdoses. This collection of articles offers some insight into how Frieden’s 6 components are operationalized in practice using an injury and violence context. These narratives also illustrate the value of a systems approach to impact public health through research and practice as mutually reinforcing pieces of the work. The contribution of this collection is that it is the first to explicitly link the way a systems approach strengthens traditional public health approaches (incorporating 6 components of implementation). The contributions as a whole provide a perspective that has never been consolidated in one place.